Nine Common Mistakes Doctors Make

By Forbes, Staying Healthy

You had better educate yourself about the latest medical breakthroughs, because there is a good chance your internist has neglected to do so.

"FIRST, DO NO HARM," counseled old Hipprocates, and doctors have been cautious ever since -- cautious to the point of sticking with outmoded, discredited medical practices. We asked doctors, medical school professors and ethicists to cite the most common ways in which doctors fail to keep up with recent scientific evidence. Here are their answers:

Peptic Ulcers, in most cases, are due to a bug called Helicobacter pylori. If you go to a doctor with stomach pain, you should get a $20 blood test and, if it is positive for the bug, you should get a $300 barium scan to pinpoint any ulcer. In most cases, your doctor should then prescribe antibiotics. Yet, according to a 1997 study by the Centers for Disease Control & Prevention, half of all doctors treat ulcers merely with antisecretory agents to combat stomach acid.

Heart Attack Survivors should get beta-blockers to cut their blood pressure, beginning right in the hospital. This policy is based on massive studies and endorsed by national medical organizations. Yet doctors prescribe beta-blockers to only one in three patients. Heart attack patients should also start on aspirin within two days of hospitalization, yet 40% do not. Angiotension converting enzyme (ACE) inhibitors, which lower blood pressure and reduce the burden on the heart, are also underprescribed.

High Blood Pressure is UNDERTREATED. "Only 70% of people with hypertension are detected, and that's not so much the physicians' fault," says Richard Paternak, Director of Preventive Cardiology at Massachusetts General Hospital and Harvard Medical School. "But only 55% are treated, and only 25% are treated to the proper goal, and that is the physicians' fault."

Doctors also often fail to push cholesterol-lowering pills. A doctor may start a patient on a low dose of an anticholesterol drug, and when the patient doesn't come back for an adjustment, that dose become permanent. Why don't doctors make the effort to see the patient again and adjust the dose? Probably because of a wrong assumption: that the drug won't make much of a difference.

Juvenile Diabetes Patients - who require insulin injections from the day of diagnosis - should test their blood sugar at least four times a day and inject insulin at least three times to keep blood sugar as close to normal as possible and thus lessen the risk of complications like kidney failure and blindness. This therapy has long been accepted by specialists, and it received rock-solid support from a hugh trial published in 1993. Yet most doctors still prescribe only one or two shots a day.

"When a major advance in medicine occurs, it takes about ten years to change the way doctors practice," says Irl Hirsch, an endocrinologist at the University of Washington. Only 40% of juvenile diabetes patients get three or more shots a day.

Asthma Patients with moderate or severe cases should inhale steroids to fight the inflammation, but most don't. Michael Kaliner, head of the Institute for Asthma & Allergy in Washington, D.C., says that 25% to 30% of asthmatics are on steroids, half as many as should be. Last year about 5,600 people died from asthma attacks.

Doctors are leery of steroids because these powerful drugs have serious side effects when used for the long-term treatment of rheumatoid arthritis and other autoimmune diseases. But in asthma treatments the drug doesn't leak much beyond the target organ, the lungs. So doctors should prescribe steroids a little more liberally.

Morphine is underprescribed for dying patients. Trained to be careful not to let postoperative patients become addicted to narcotics, doctors are too timid in using it among people for whom addiction is hardly a worry. Half of dying patients suffer from very severe pain, according to a study by The Robert Wood Johnson Foundation.

Infections Caught In The Hospital cause an estimated 77,000 deaths a year. Many are surely caused by bad hygiene, as attested to in a study by the Centers for Disease Control & Prevention finding that 14% to 59% of doctors and 24% to 45% of nurses did not wash their hands between patient visits.

"I suspect those numbers are even higher," says Brobson Lutz, the former Director of Public Health in New Orleans, now in private practice as an internist. In 1993 Lutz had medical students stake out the toilets at a convention of infectious disease specialists. They found that only 68% of 498 doctors washed their hands. Why the lax attitude? "Antibiotics," Lutz replies. "We've grown complacent. If this study had been done 50 years ago, it would have found very different behavior."

Depression is grossly underdiagnosed, says Peter I. Juhn, head of Kaiser Permanente's Care Management Institute in Oakland, California. A questionnaire asking whether patients have had trouble sleeping, whether they cry a lot, whether they lack energy and so forth, can tease out most cases. "It's simple, but underused," he says.

Data Mix-Ups caused not by individuals but by collective incompetence cause most medical errors committed inside hospitals.

Last year Norman J. Petterson, 44, a computer consultant in Mentor, Ohio, sweated bullets by the bedside of his grandson, who was hospitalized with leg pains. "My wife and I'd be sitting there and the orthopedic team with march in and ask us what had been done today," he says. "The infectious disease people would ask later what the surgeons did. If there was a paper record, nobody consulted it. We had become the conduits of information."

One way to avoid such snafus is by requiring doctors to enter observations and orders in a hospital-wide database, such as the wireless system that recently went live at the Montefiore Medical Center in New York City. The system forces physicians to make the entries themselves, not leave the work to nurses. The database flags possible drug interactions and reminds doctors to follow certain guidelines.

Hospital record keeping leaves a lot to be desired. One study showed that out of hundreds of written requests by very sick people that they not be kept on life support, just 22 proved accessible to doctors.

What are we to make of this litany of medical folly? David M. Lawrence, Chief Executive of the Kaiser Foundation Health Plan & Hospitals, attributes just about all of it to system failure, rather than to individual doctors who don't do their homework.

"Compare medicine to the aviation industry," he says. "You don't have pilots trying to do it all by themselves - they operate in teams, with incredible support. When they are recertified, they are not just tested on book learning but in simulators. They work together to keep their skills up to date. But in medicine 85% to 90% of doctors operate alone, or in small groups that at most share calls. How can they keep up with the 1,300 medical articles published every day?"

What's a patient to do? Take charge of your health care, seek second opinions - and make sure someone you trust second-guesses your doctors when you can no longer do so yourself.

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